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RESTARTING YOUR LAB A PATHWAY TO RESUMING DIAGNOSTIC TESTING DURING COVID-19 Matt O’Brien MS RRT RPFT FAARC May 5, 2020
RESTARTING YOUR LABA PATHWAY TO RESUMING
DIAGNOSTIC TESTING DURING COVID-19
Matt O’Brien MS RRT RPFT FAARC
May 5, 2020
BACKGROUND / DISCLOSURES
o I manage the pulmonary labs at the University of Wisconsin Hospital and Clinics in Madison Wisconsin
o We have approximately 12 staff that cover 4 separate testing sites in the Madison area.
o We have been doing “essential” testing and are in the process of restarting our lab.
o We use a variety of vendor equipment for clinical and research related applications.
o References will be made to a variety of equipment types and are for example only.
o
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CONSEQUENCES…COVID-19
Global pandemic
Economic pandemic
Hospital pandemic
Sickness,
Death
Job losses
Business failures
Loss of revenue,
Staff layoffs and pay cuts
Preparedness
phase
Patient surge
phase
De-escalation or
reopening phase
WHY THIS TALK? o This is a historic event for everyone and especially for
respiratory care.
o There are many unknowns about the SARS-CoV-2, (COVID-19) virus, its transmission, and how to safely proceed with pulmonary testing.
o Cardiopulmonary labs, clinics and research facilities all need guidance to restart services.
o To avoid further transmission, we need to proceed with caution and focus on safety.
o When is it likely safe to resume testing?
ANSWERING WHEN…IS NOT SIMPLE
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OBJECTIVES: RESTARTING PULMONARY DIAGNOSTICS-DURING COVID-19
o Review of ATS initial, expected and ERS guidance.
o Consider your location: Is the prevalence high or low?
o Explore strategies to help you safely restart diagnostic testing.
o How does the CDC define an aerosol generating procedure?
o Discuss when it is wise to obtain a negative COVID-19 test prior to seeing at patient?
o What infection control practices make sense for pulmonary diagnostics and COVID-19.
o Equipment and testing considerations.
o What role can remote monitoring / telemedicine play?
INITIAL GUIDANCE ATS
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March 2020
KEY POINTS OF INITIAL RECOMMENDATION o PFT testing could represent an avenue for transmission,
because of congregation of patients, coughing and droplet formation surrounding PFT procedures.
o Risk may be significant based on the prevalence, age, severity of lung disease and presence of immunosuppression.
o Limit testing to essential for immediate treatment decisions
o Limit type of testing to essential.
o Implement measures to protect patients and staff.
o Use appropriate PPE
o Enhanced cleaning of testing spaces
o Balance potential risk against need for assessment of lung function to make Rx decisions.
o Risk benefit ratio will change over time8
OUR EXPERIENCE
o We limited testing to “essential” or urgent testing needed for immediate treatment decisions.
o Over the last 2 months we performed testing on 143 patients / 303 procedures using minimal staff
o We implemented full PPE during all testing (N95, face shield, gown, gloves, and changed the pneumotach out between each patient.
o We ran a HEPA filter in the PFT testing rooms.
o Patients were not required to have a nasal swab test for COVID-19.
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DEVELOPING YOUR PLAN TO SAFELY OPEN YOUR PULMONARY OR CPX LAB
o Prevalence: In the local community/surrounding areas.
o Patients: Prescreen using current recommendations.
o Equipment: Implement additional safety measures to minimize the potential for cross contamination.
o Testing environment: Find solutions to reduce aerosol contamination (patient, nebulizers)
o Time: Allow extra time between patients for disinfection practices and reduce PPE fatigue.
o Review / update your plan as conditions change.
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SHOULD PATIENTS SCHEDULED FOR A “PFT” BE REQUIRED TO HAVE A NEGATIVE
COVID TEST PRIOR TO THE VISIT?
o It depends…
o What specific PFT test is ordered?
o Is the procedure considered “aerosol generating” by CDC?
o Is the patient symptomatic?
o What is the local prevalence of COVID-19?
o Does prescreening suggest a high or low risk patient or community for infection?
o What is your infection control department guidance?11
THE LOCAL PREVALENCE OF COVID-19
o What is going on in your area?
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WHAT IS AN AEROSOL GENERATING PROCEDURE?
AEROSOL GENERATING PROCEDURES (AGP)
CDC.gov
AEROSOL GENERATING PROCEDURES PER THE CDC
CDC.gov
ARE ALL AEROSOLS INFECTIOUS?
CDC.gov
ATS: The use of MDIs should be used when at all possible to minimize
the risk of excess aerosol that maybe infectious
PATIENT & COMMUNITY RISK
Low
o No new symptoms
o History of self monitoring.
o No known contact with someone who was ill.
o Symptoms of cough or sputum production are consistent with the known or underlying chronic disease process.
o Local ID and Public Health report local prevalence is reduced
High
o New or multiple symptoms
o Family member is / was ill.
o Temp was 100 or greater recently or on arrival.
o Nursing home or long term care worker or resident.
o Food processing plant
o “Essential” worker
o Multi family household?
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TWO APPROACHES: TO DECIDE WHETHER TO SCHEDULE A COVID TEST PRIOR TO PFT VISIT
o Consider all cardiopulmonary testing to be aerosol generating procedures:
o Require a negative COVID test prior to pulmonary testing.
o Assess each patient and visit carefully for risks and probability.
o Aerosol generating procedure: Obtain test for COVID prior.
o Higher probability: Obtain test for COVID prior.
o Low probability: Pre-screen and use appropriate PPE
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#1 #2
TESTS WE PERFORM
o Spirometry pre/post
o Lung volumes (Pleth & Dilutional)
o Diffusion
o ABG
o 6MWT
o RMF
o LCI
o Shunt / HAST
o Breath hydrogen testing
o Sputum induction
o Pentamidine administration
o Bronchoprovocation
o Methacholine challenge
o Exercise
o EIB w/cold air
o Mannitol
o Cardiopulmonary exercise (VO2)
o Metabolic testing (REE)
19Text in red are procedures I feel fall into the category of known or potential aerosol
generating procedures because of high ventilation and risk of significant coughing
PRESCREENINGTHE PATIENT
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SYMPTOM PRE-SCREENINGPATIENTS AND STAFF
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Be on the alert for any new and unexplained symptoms
PRE-SCREENING PATIENTS PRIOR
TO PFTS
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• Form is completed for each
patient
• EMR
• Phone screening
• Is testing requested
appropriate or needed?
• Consult ordering
provider if patient has
high risk factors
SHOULD WE PERFORM PULMONARY FUNCTION TESTING ON PATIENTS SUSPECTED
OR + FOR COVID-19?
NO… Wait until after they
recover and have a negative test.
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SHOULD WE PERFORM PULMONARY FUNCTION TESTING ON PATIENTS WHO
HAVE FLU LIKE SYMPTOMS?
NO… Wait until after they recover and have a negative test.
SCREENING WHEN THE PATIENT ENTERS THE CLINIC OR HOSPITAL
o Self monitoring?
o New symptoms?
o Temperature?
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ENABLE SPACE FOR SOCIAL DISTANCING WHEN CHECKING IN AND IN SEATING AREAS
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THE PATIENT WAITING AREAS
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Rearrange furniture or tape off areas in patient waiting areas
STAFF WORKSTATIONS SHOULD ALSO BE SEPARATED
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HAND HYGIENE
o Patients and staff should perform wash hands or gel prior to and at end of testing.
o Gel in / Gel out!
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PERSONAL PROTECTIVE EQUIPMENT
o High risk patients and communities require full PPE: N95 mask, face shield, gown and gloves.
o Low risk patients / communities require a surgical mask
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FILTERS SHOULD BE USED
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o Exceptions include:
o disposable ultrasonic mouthpiece / flow sensors.
o During a CPX test
o Dosimeters
SOCIAL DISTANCING DURING SPIROMETRY IS
POSSIBLE
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• Consider cable length
• Most vendors offer ample cable
length.
MGC CPF/D: 10 feet with USB cable
PRACTICE SAFE SPIROMETRY
o Maximize distance when possible
o Use a filter
o Instruct patient to wear mask between breathing maneuvers
o Cough etiquette
o Have tissues ready or dispense ahead of time
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SOCIAL DISTANCINGBODYPLETHYSMOGRAPHY
o Bodyplethysmography…depends on your system
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CARDIOPULMONARY EXERCISE TESTING
o Social distancing is more challenging.
o Umbilical length is approximately 8 feet long.
o Increased risk of droplet contamination because of high ventilatory rates.
o No filter during CPX testing
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6MWTSOCIAL DISTANCING IS POSSIBLE
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o The blue tooth communication to a device/tablet will enable distancing for some patients.
WIRELESS SPIROMETRYANOTHER TOOL TO AID IN DISTANCING
o There are several devices on the market that communicate via blue tooth.
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FENO
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• Controversies exist regarding filter efficiency
• Some devices include inspiratory and expiratory efforts,
others are expiratory only.
• Additional evaluation is needed. (Double filter media?)
EQUIPMENT INFECTION CONTROL
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CDC GUIDANCEDISINFECTION OPTIONS
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CDC.gov
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PULSE OXIMETRY
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High touch surfaces need cleaning after each patient
FLOW SENSING DEVICES
o Follow the manufacture recommendations for cleaning / use.
o Wipe off any high touch surfaces with a disinfecting wipe.
o Allow adequate contact time
o Several are single patient use.
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THE BREATHING CIRCUIT OR ASSEMBLY
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• Follow the manufacture recommendations for
cleaning.
• If you are testing a high risk patient or are in an area of
high prevalence you could change out between patients.
SAMPLE LINES
Gas sample lines aspirate gas during rapid gas analysis for:
o PFT
• DLCO
o Gas exchange
• VO2 max
• REE
o Lung clearance index
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• Wipe tip of sampling connection / interface.
• If contaminated with secretions blow out from
reverse side.
• Do not flush with alcohol.
• Avoid saturating naphion with disinfecting
wipes
INFECTION CONTROL RELATED TO THE TESTING ENVIRONMENT
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Relating to the recommendations used for
performing PFTs given a diagnosis of Cystic
Fibrosis
1. Negative pressure rooms
2. HEPA filtration
3. 30 min wait between patients
AIRBORNE ISOLATION INFECTION ROOMS(AIIRS)
CDC.gov
PFT NEGATIVE PRESSURE ROOMS
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True negative pressure rooms should have an indicator just outside of the room.
WOULD TESTING OF A PATIENT CONSIDERED A HIGH RISK PATIENT OR IS FROM A HIGH RISK COMMUNITY NEED TO BE TESTED IN A ROOM CAPABLE OF
NEGATIVE PRESSURE?
YES*
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*According to the expected ATS recommendation… I suggested, “or in
a room using a hospital grade HEPA filter”.
HEPA FILTRATION
o Multiple manufactures of hospital grade devices
o Portable
o Variable fan settings
o Cost ~$1,800 each
o Is this required?
EXTRA MEASURES TO CONSIDER FOR THE TESTING ENVIRONMENT
UVC Light Room Disinfection• Performed by hospital environmental
services department.
• Multiple cycles of light over 15-30 minutes.
• Done once per week
• Cost prohibitive for most.
• Is this essential?
TELEMEDICINE AND REMOTE MONITORING
o Telemedicine is now a vital tool.
o Home spirometry has evolved significantly
o Costs for home spirometers vary depending on:
o Design
o Accuracy
o Parameter outputs
o Connectivity to a portal
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EXAMPLE: PLAN ON RESTARTING
o Work with your hospital infectious disease and local public health authority to determine prevalence in your area.
o Hospital based labs may need to obtain approval from administration.
o All staff should be trained regarding the approved plan to prevent resurgence.
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ATS EXPECTEDRECOMMENDATIONS –13 SLIDES
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Expected ATS
Recommendations
Four General Recommendations
#1: Understand the prevalence of
COVID-19 in your community and
those from which referrals may be
coming from
Expected ATS
Recommendations
Community Prevalence
In high prevalence communities testing must
be more restrictive, testing should be done
only if absolutely necessary
A negative COVID-19 test is less reliable in a
high prevalence community because there are
a greater number of false negative subjects in
the community
Expected ATS
Recommendations
Community Prevalence
In low prevalence communitiesa negative
COVID-19 test is more reliable because there
are fewer false negative subjects in the
community
Under these conditions pulmonary function
testing may be less restrictive
Expected ATS
Recommendations
Community Prevalence
Community prevalence should be determined
by consultation with local infectious disease
and public health authorities
Under no circumstances should COVID-19 +
patients or those with flu-like symptoms be
tested
Expected ATS
Recommendations
Four General Recommendations
#2 Weigh the risks/benefits of PFTs
Pathogen Exposure vs. Clinical Importance
Expected ATS
Recommendations
Weigh the risks/benefits of PFTs
Some Examples of Essential PFTs
• Evaluate transplant or resection candidacy
• Monitor for bronchiolitis obliterans syndrome
in transplant patients
• Preoperative risk stratification
• Diagnosis of idiopathic or complex dyspnea
• Monitor patients at risk for drug-related
pulmonary toxicity
Expected ATS
Recommendations
Four General Recommendations
#3 Only perform tests that are essential
Expected ATS
RecommendationsOnly perform tests that are essential
• Spirometry with or without DLCO
• If post BD testing is necessary, MDIs are preferred over nebulizers
• Lung volumes less frequently affect clinical decision-making
• Bronchoprovocation and exercise tests should be post-postponed if possible due to the higher risk of aerosol production from high minute ventilation and coughing
• Consider home spirometry for patients requiring on-going surveillance
Expected ATS
Recommendations
Four General Recommendations
#4 Appropriate precautions and disinfection
procedures must be followed
Expected ATS
RecommendationsAppropriate precautions and disinfection
• Video-based language interpreters are recommended
• Patients and staff must clean their hands before and after testing
• Filters must be used
• Instruct the patient in cough etiquette and provide tissues before testing begins
• Patients should wear surgical masks when not performing a testing maneuver
Expected ATS
Recommendations
Appropriate precautions and disinfection
High Risk Patients/High Risk Communities
• Testing should be done in a negative
pressure room
• Staff should wear full PPE including N95
mask, gown, gloves, and face shield
Expected ATS
Recommendations
Appropriate precautions and disinfection
Low Risk Patients/Low Risk Communities
• Staff should wear a surgical mask during
testing to avoid exposure to aerosols
Expected ATS
Recommendations
Appropriate precautions and disinfection
• Equipment should be disinfected according
to the manufacturer’s instructions
• Local policy should dictate cleaning
procedures between patients, and time
allotted between patients to allow adequate
room ventilation
KEY POINTS OF THE ERS RECOMMENDATIONS
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Pandemic phase (Postpone all routine testing)
Limit testing to Spiro and DLCO
Telemedicine for remote testing with video coaching
High community prevalence
Level 1 safety recommendations(Full PPE)
Test in a neg pressure room
Eye protection: goggles or face shieldGloves Hand hygiene protocols for patient and staff.
HEPA filters are NOT recommended (viral colonization)
KEY POINTS OF THE ERS RECOMMENDATIONS
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Post Peak phase(All testing can be reintroduced with extra precautions including: Exercise testing, nebulization, Bronchoprovocation.)
Low community prevalence
Level 2 safety recommendationsFull PPE and mask guided by locate policy
• Use filters to minimize escape of aerosol from exhalation ports when
using nebulizers.
• Filters for CPX testing suggested but not recommended (Full PPE)
KEY POINTS OF THE ERS RECOMMENDATIONS
o Screening patient referrals and prioritize patients. Use triage questionnaire.
o Reorganize waiting areas, testing rooms, staff spaces to minimize transmission of the virus. (IP / OP space)
o Ventilate room (min 15 min)
o Recalibrate equipment after decontamination.
o HEPA Filters not recommended because of possible viral colonization.
o Spiro devices without filters should be adapted to accommodate a filter.
o Post Pandemic Phase –Level 3 safety (return to normal) 70
ERS TRIAGE QUESTIONNAIRE
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HOW WILL COVID-19 CHANGE PULMONARY DIAGNOSTICS?
o The volume of testing and FTE may decrease.
o Ordering frequency and scope of testing
o Additional time for:• Prescreening patients
• Appropriate PPE
• Room and equipment cleaning
o The ease of equipment cleaning related to infection control - will be more important.
o Negative pressure rooms for all hospital PFT rooms will be the norm.
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REVIEW
o Know the prevalence of the virus in your area and the surrounding areas.
o Develop a method to prescreen patients in advance of testing.
o Considering your testing environment; are you allowing enough time for appropriate disinfection?
o Considering your PFT or CPX equipment: what additional steps can be implemented to enhance patient safety?
o Perform only essential testing when in an area of high prevalence.
o Keep up to date regarding additional recommendations from the CDC, ATS and ERS.
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THANK YOU
oMGC DIAGNOSTICS
o Jeff Haynes for expected ATS recommendations
o EVERYONE IN ATTENDANCE
Matthew J. O’Brien MS RRT RPFT FAARC
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Common Cannister Method Bronchodilator Administration
SAFE HANDLING OF LAUNDRY FROM WORK
o Transport clothes in a plastic bag if removed prior to exiting the healthcare environment.
o Perform hand hygiene after handling dirty laundry
o Wash and dry laundry at the highest temp the fabric can stand to kill germs
o When providing direct care to COVID-19 or persons of interest patients; remove scrubs/work attire either at the end of a shift or immediately after arriving home. Place clothes in plastic bag for 48 hours before laundering. Throw away plastic bag-do not reuse.
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